Online Therapy Improves Access to Pain Patients

August 12, 2015

Cognitive behavior therapy can have strong benefits for patients living with persistent pain, but getting access to this form of health care can be a logistical issue for some patients. An online program may be a viable alternative, but how effective is it compared to face-to-face counseling?

Chronic pain patients are locked into a daily battle with their symptoms. For years, physicians have found success using a biopsychosocial approach to treating persistent pain, including cognitive behavior therapy (CBT).1,2

CBT teaches patients to avoid negative thought patterns, like pain catastrophizing and ruminating, and instead develop strong coping methods and a sense of self-efficacy, helping them to live healthier lives and even take fewer medications.

“We know from multidisciplinary pain centers and researchers that people have the best results when they combine medication with other things,” like CBT, said Marian Wilson, PhD, MPH, RN-BC, an assistant professor in The College of Nursing at Washington State University.

However, getting this type of treatment to all Americans isn’t easy. Many people don’t have access to pain specialists and psychologists, especially if they live in rural areas. Lower socioeconomic patients also may lack transportation or be unable to find adequate insurance reimbursement for such services.

“The question is: How do you make that accessible to people?” said Dr. Wilson. According to her new study, the answer could be the internet, something that approximately 83% of Americans now use.3 While CBT is traditionally talk-based, online-designed programs may present a viable alternative, though the efficacy of this medium is still being studied researchers.

For instance, while positive results have been found in specific patient populations, like fibromyalgia, headaches, arthritis, and angina,4-6 there’s been little evidence that widespread use of an online CBT program would be beneficial to the greater population of chronic noncancer patients.

Internet-Based Cognitive Behavior Therapy

Dr. Wilson and her team, therefore, conducted a randomized, controlled trial, enrolling 92 individuals in the Chronic Pain Management Program, an eight-week online course offered by Goalistics. The program works by evaluating an individual’s scores for pain intensity, pain interference, and emotional burden, and then tailoring a series of learning modules designed to help reinforce positive thinking and better pain self-management.

All of the patients had similar baseline characteristics, suffering from chronic noncancer pain and taking some form of opioid medication. Most of the patients were women (78%), though ages varied widely from 24 to 78 years. Forty-five patients were placed in the experimental treatment group, while the other 47 acted as a control group.

The course seemed to influence positive changes in the treatment group, where improvements were found in pain intensity, pain interference, and depression scores. The patients also showed significant improvements in their self-efficacy, which reflects a person’s ability to feel in control of their pain.

“We know that if people learn more about how to manage their pain, they feel more confident about their pain,” said Dr. Wilson. Interestingly, patients in the control group showed reduced self-efficacy scores.

The Findings

The online program may have also influenced how patients used their opioid medications. A sizeable 20.9% of the treatment group reported a decrease in their need for opioids or stopped opioid prescription altogether, compared to just 6.8% in the control group.

And while this could be coincidental, results further suggested the online program could have helped stem opioid misuse behaviors, as well. At baseline, roughly half of each group were reporting scores for misuse behaviors, but by the end of the course, 16.3% showed improvements, compared to 8.9% in the control group.

The online medium does have notable conveniences. Using self-directed, self-paced courses lets patients complete the program flexibly within their personal schedules, and the anonymity of the internet may relieve them of feeling stigmatized about receiving therapy for their condition.

“I do not believe a single opioid should be dispensed without, at minimum, some education about risks,” said Dr. Wilson, who suggested that doctors could even set up computer kiosks in-office to encourage more patient engagement.

Incentivizing Health Care

However, the greatest challenge could be getting patients to engage with the therapy program, itself. After all, when a patient is receiving their therapy through an internet browser rather than a trained professional, what’s to stop them from just hitting the exit button?

Only 38% of the treatment group engaged in at least half of the self-directed program, a major limitation of the study. It may also be a sign that incentivizing patients to use online therapy could make or break its success, according to Beth Darnall, PhD, a clinical associate professor at Stanford University School of Medicine in Palo Alto, California.

“We’re at the precipice of needing to dial this in. You can have the best treatment in the world, but if patients don’t engage in it, it’s doesn’t mean much,” said Dr. Darnall, who has had her own success developing an online perioperative pain psychology program.

“As a field, we have to be thinking much more along these lines—about really how to engage people, how to motivate them, how to incentivize them—and there’s multiple ways to do it, but it’s really a science unto itself.”

The surge in popularity of smartphones and tablets could provide other useful mediums, as well. At the moment, Dr. Darnall said she and her team are in the process of developing mobile applications to work in tandem with out-patient care.

The internet does seem to be part of the future of health care, said Dr. Darnall, where broader access to better treatments is made possible through ever improving, ubiquitous technology.

“The next layer is how we optimize engagement with patients. And no one really has that figured out,” she concluded.

Dr. Wilson, et al.’s pilot study was supported in part by the Washington State Life Sciences Discovery Fund. The research was conducted as part of Dr. Wilson’s doctoral dissertation, which can be found published in its entirety in an online database with ProQuest/UMI Dissertation Publishing. The authors declared no conflicts of interest.

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